General Medicine Flashcards
AAA screening
One time abdominal ultrasound for AAA in men between 65-75 in anybody who has ever smoked (100 cigarettes)
Decreases risk of death by 14% over 10 years
Lung cancer screening
Annual low dose CT in patients 55-80 with 30-pack-year history, who currently smoke of quit within 15 years
Pneumococcal vaccine
PPSV23 rec for all adults >65yrs of with other risk factors (asthma, DM, cirrhosis, asplenia). Dual vaccination provides best risk reduction.
PVC13 first, PSSV23 6-12 months later
Colonoscopy screening
If average risk, colonoscopy every 10 years starting at age 50
OR
Flex sig and fecal occult blood testing every 5 years
Zoster vaccine
Recommended for imunocompetent adults >60YO, regardless of history of chickenpox, shingles, or prior vaccination
STD screening (Chlamydia/Gon, HIV, and HPV)
Chlamydia: women under 25YO, men or women with high risk practices
HIV: all persons b/w 13 and 64 yrs
HPV: all women 9-26YO, men 11-21YO
Blood pressure targets
If 60YO: less than 150mmhg systolic
Which four groups of people should be on a statin?
- Known atherosclerotic disease
- 10-year risk of developing atherosclerotic disease >7.5%
- LDL>190
- Diabetes
Tx with high intensity atorvastatin (40mg or 80mg) or rosuvastatin (20mg or 40mg) if
What antidepressants are associated with weight loss?
Buproprion - contraindicated in patients taking MAO-i inhibitors or with seizures, eating disorders, psychiatric illness
Topiramate
When is it indicated to get bariatric surgery?
BMI >40
or BMI 35-40 with DM, OSA, or joint disease
What is the treatment for cocaine-induced chest pain?
Calcium channel blockers and benzodiazepines
What is the management algorithm for influenza A?
Early antiviral treatment, within 2 days of symptom onset, in hospitalized pts; severe illness; risk factors incl CV dz, CKD, cancer, liver disease, immunosuppression
Oseltamivir or zanamivir- influenza A, B, or unknown
Amantadine and rimantadine - Influenza A only. Widespread resistance, not recommended for community circulating strains.
What are the Wells Criteria for PE?
3 - signs and symptoms of DVT
3 - PE most likely
1.5 - HR >100
1.5 - 3 days immobilization or surgery in past 4 weeks
1.5 - previous PE or DVT
1 - hemoptysis
1 - malignancy, palliative or treated in last 6 months
Mallory-Weiss Tear vs Boerhaave syndrome
MW: Upper GI mucosal tear, caused by forceful retching, may have submucosal bleeding. Dx by EGD.
Boerhaave: esophageal transmural tear, caused by forceful retching, with esophageal air or fluid leakage into pleura. CT wiht gastrografin confirm dx. Amylase in pleural fluid.
Hereditory spherocytosis
Autosomal dominant
Lack of spectrin
Tx with oral folate, blood transfusions, splenectomy if refractory
If splenectomy, vaccinate with pneumococcal, hemophilus, and meningococcus, and daily penicillin prophylaxis for 3-5 years, as risk of sepsis present for 30 years
Pseudogout
Acute calcium pyrophosphate crystal arthritis
Most common in knee
Inflammatory (15K-30K cells), with CPPD crystals (rhomboid, positive birefringent)
Chondrocalcinosis or chronic calcification on imaging
Tx glucocorticoid injections, NSAID, colchicine
Gout
uric acid arthritis
Inflammatory (<50K), crystal (needle-shaped, negatively birefringent), in ankle or toe.
Tx NSAID, colchicine, corticosteoids
Chronic prophylaxis if >2 attacks per year or presence of tophus: with allopurinol (xanthine oxidase inhibitor), febuxostat (XO inhibitor), or probenecid (uricosuric, use in underextreters, risk of stones), decrease intake of meat, alcohol, seafood, avoid diuretics
What therapies can be used for BPH?
Alpha1 blockers: doxazosin, tamsulosin
5-alpha reductase inhibitors: finasteride
Babesiosis
Babesia microti, of Ixodes tick
Sc anemia, thrombocytopenia, flu-like sx
Labs show intravascular hemolysis (indirect high bilirubin, high LFT, high LDH, reticulocytosis)
Blood smear shows intracrythrocytic rings (Maltese cross)
Tx 7-10 days atovaquone + azithromycin OR quinine + clindamycin
Rocky Mountain spotted fever
Fever, HA, myalgia, rash that spreads centripetally and includes palms and soles
Most prevalent rickettsial illness in the US
Who is treated for hepatitis B?
Acute liver failure, cirrhosis, high serum HBV DNA, positive HBeAg and elevated ALT, or to prevent reactivation during chemotherapy/immunosuppression
What are treatments for HBV?
Interferon – short term, use in younger compensated patients, not in decompensated cirrhosis
Lamivudine – use in HIV patients
Entecavir – use in decompensated cirrhosis
Tenofovir – potent, low resistance, 1st line tx
What is the treatemtn for HCV?
Pegylated interferon plus ribavirin, +/- telaprevir for genotype 1
Statins
HMG-CoA reductase inhibitor: reduce conversion of HMG CoA to mevalonic acid, and increase number of LDL receptors
myalgias in 2-10% of patients (symmetrical, proximal) via decreased coqnzyme Q10 synthesis
G6PD deficiency
molysis after infection or medication (sulfa drugs, antimalarial, nitrofurantoin, TMP-SMX)
Lab +Prussian blue stain for hemosiderin
Smear Heinz bodies in RBC membrane
What metabolic abnormalities are associated with hypothyroidism?
Hyperlipidemia Hyponatremia Elevated CK Elevated LFTs Normocytic, normochromic anemia Thyrotoxicosis may cause hypercalcemia
How do you manage hypothyroidism in pregnancy?
T4 requirements increase 30-50%
Increase in first, possibly second trimester, then repeat measurement in 2-4 weeks
Estrogen decreases TBG clearance, increasing TBG total, which decreases free T4 and increases TSH
What are the two main diseases causing hypothyroidism, and what is the clinical sx of the thyroid gland?
Hashimoto - autoimmune - nontender thyroid
Subacute/lymphocytic - post-viral/post-partum - tender thyroid
What are the screening recommendations for type 1 and type 2 diabetes?
Type 1 - fasting lipid panel
Type 2 - retinopathy, neuropathy, nephropathy, dyslipidemia
DKA is associated with what electrolyte abnormality?
Hyperkalemia, 6-7mEq
with treatment (insulin), rapidly develop hypokalemia (4-4.5) due to depleted intracellular K in total body, effective tx should add K to IV fluids
DKA is associated with what acid-base status?
High Anion gap metabolic acidosis
Increased H, decreased HCO3
What are the screening recommendations for osteoporosis?
DEXA for women 65 or older, or younger women with risk factors
Risk factors: family history, low BMI, smoking history, steroid use, antiseizure meds
Treat if risk of fracture in 10 years is 20%, or 3% risk of hip fracture
In men or younger patients, screen for secondary cause (celiac, hypogonadism, malabsorption, hyperPTH, multiple myeloma)
What is the definition of osteoporosis?
DEXA < -2.5 or presence of fragility fractures (compression fractures of vertebra, fracture of femoral neck, colles fracture of distal radius)
What are the electrolyte imbalances associated with primary adrenal insufficiency?
Hyperkalemia
Hyponatremia
(loss of aldosterone)
Waldenstrom macroglobulinemia
IgM spike
smear: rouleaux formation
biopsy: >10% clonal plasma cells
sx: hyperviscosity, neuropathy, bleeding, hepatosplenomegaly, lymphadenooopathy
Multiple Myeloma
osteolytic lesions, anemia, hhypercalcemia, renal insufficiency
IgG, IgA, or light cahin spikes
smear: rouleaux
biopsy: >10% clonal plasma cells
Hereditary spherocytosis
Sx hemolytic anemia, jaundice, splenomegaly
complication pigment gallstones, aplastic crises with b19
Lab high mean corpuscular hemoglobin, spherocytes on sphere
increased osmotic fragility
negative Coombs (positive in autoimmune hemolytic anemia)
abnl eosin-5-maleimide
tx folic acid, transfusion, splenectomy
What are dietary, medical and surgical therapy options for kidney stones?
Diet: low protein diet, increase dietary calcium, low oxalate diet
If stone <5mm, fluids >2L/day for conservative management
Alpha blocker (tamsulosin) Calcium channel blocker (nifedipine) For stones less than 10mm with sx controlled
Extracorporeal shock wave lithotripsy is widely used, noninvasive, tx proximal ureter or intra-renal stones
What are the guidelines for treating anemia in CKD?
Initiate EPO in CKD patients with hemoglobin <10
Target hemoglobin 10-11
What are the screening guidelines for CKD?
In patients with T1D: yearly urine albumin-creatinine after 5 years of T1D
In patients with T2D: yearly urine albumin-Cr at time of diagnosis
In patients with FHx only: serum Cr, estimated GFR, UA
Diagnosis requires elevated Al-Cr ratio on 2 or 3 random samples over 6 months
How do thiazide diuretics interact with calcium and uric acid?
(Recall: thiazides inhibit reabsorption of sodium (Na+) and chloride (Cl−) ions from the distal convoluted tubules in the kidneys )
Decrease uric acid excretion, causing hyperuricemia and may potentiate gout
Lower urinary calcium excretion, making them useful in preventing calcium-containing kidney stones
Obesity hypoventilation yndrome
BMI>30, awake hypercapnia
Restrictive PFTs, chronic respiratory acidosis
Phys: alveolar hypoventilation
Tx with NPPV, weight loss
What are the extrahepatic manifestations of chronic hepatitis C?
Essential mixed cryoglobulinemia
Membranoproliferative GN
Porphyria cutanea tarda or lichen planus
Increased risk of diabetes
Neutropenic fever
ANC <1500
Usually pseudomonas or GNOs
Tx with antipsueodomonal beta-lactam: cefepime, meropenem, piperacillin-tazobactam (
AIN
Caused by penicillin, TMP-SMX, cephalosporin, NSAIDs
maculopapular rash, fever, AKI
urinary eosinophils
What is the treatment for syphilis? What about in a penicillin allergic patient?
Primary or secondary: Penicillin IM x1 or Doxycycline PO x 14 days
If latent: penicillin IMx3 or doxy x28 days
If tertiary: Penicillin IV x 14 days or ceftriaxone x 14 days
If penicillin allergic: if early syphilis, choose doxy. If CNS or pregnancy, go with penicillin desensitization.
How do you manage hypercalcemia?
If symptomatic or calcium >14:
Short term: NS, avoid loop diuretics (volume depletion
Long term: bisphosphonate
If moderate or asymptomatic:
Avoid thiazide, lithium, volume depletion, and bed rest
What do you treat Bell’s palsy with?
Prednisone PO
How do you manage hypertension in ischemic stroke?
Maintain BP of less than 220/120
When do you admit a TIA patient to the hospital?
Age >60 =1 BP >140/90 =1 Hemiparesis=2 Duration 60min=2 Diabetes=1
If score is 3 or greater, admit to hospital
What is conservative, nonmedical management for essential tremor?
Increase sleep, decrease caffeine
When do you treat gout prophylactically?
> 2 attacks in 1 year = recurrent
Start colchicine (antiinflammatory) and allopurinol or febuxostat (urate-lowering)
What is acanthosis nicgracans associated with?
Younger individuals, in groin/axilla/neck: insulin resistance or diabetes or PCOS
older individuals, in uncommon areas, or with weight loss: GI and GU cancer
What is pyoderma gangrenosum associated with?
Inflammatory bowel disease
What are the derm manifestations of Hep C?
Porphyria cutanea tarda
Curaneous leukocytoclastic vasculitis (palpable purpura) 2/2 cryoglobulinemia
Dermatitis herpetiformis is associated with what?
Celiac disease
What skin manifestations are asssociated with HIV?
Sudden onset severe psoriasis
Disseminated molluscum contagiosum
Squamous cell carcinoma
Keratinized nodules with rough surface, thickened, ulcerated, crusting, bleeding.
Most common malignancy of lip
May have early perineural invasion leading to numbness and paesthesia
Biopsy shows keratin pearls
Basal cell carcinoma
Pearly, flesh-pink nodule, with telangiectasia, on head or neck
May also have open sore that bleeds or crusts, central ulceration
Pemphigus vulgaris
Flaccid bullae, mucosal erosions
Path: intraepidermal cleavage, acantholysis, intercellular IgG
Bullous penphigoid
Pruritic bullae, tense
Path: subepidermal cleavage, IgG at basement membrane
Sebhorrheic keratosis
“stuck on”
benign epidermal tumor; tan or brown, well-demarcated border
tx not usually required
Seborrheic dermatitis
Fine, yellow, greasy-looking scales
Associated with Parkinsons and HIV
Topical ketoconazole/selenium sulfide
Iron deficiency vs chronic disease iron labs
Iron deficiency: low iron, high TIBC, low ferritin, high RDW
Chronic disease: low iron, low TIBC, high ferritin, normal RDW
If mixed, will have low iron but may have normal TIBC/trasferrin and normal ferritin
